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<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Virtual Heart Museum</title>
<link rel="stylesheet" type="text/css" href="<?php echo site_url('style.css'); ?>">
</head>
<body>
	<h1>New User Registration</h1>
	 	<p> 
         To register your institute and contribute to the museum, please submit the following form and you will be contacted shortly regarding approval of your request. </p>
         	
          <p>
          We thank you for your interest! </p>
          <form name="registration_request" action="<?php echo site_url('index.php/welcome/registration_request');?>" method="post">
		            <table cellspacing="10">
		           <tr> <td>
		             <p>Full Name: </p></td> 
		           <td>  <input type="text" name="name" /> </td>
		           
		          <!--  <td align="right">
		              <p>Address: </p></td> 
		            <td>  <input type="text" name="address" /> </td>
		           
		           </tr>
		           --> 
		           <tr> <td>
		             <p>Institution: </p></td> 
		           <td>  <input type="text" name="institution" /> </td>
		           
		            <td align="right">
		              <p>Phone #: </p></td> 
		            <td>  <input type="text" name="phone" /> </td>
		            
		           </tr> 
		           <tr> <td>
		             <p>Department: </p></td> 
		           <td>  <input type="text" name="department" /> </td>
		           
		           <td align="right">
		              <p>Email: </p></td> 
		            <td>  <input type="text" name="email" /> </td>
		            
		           </tr> 
		            <tr> <td>
		              <p>Other Information: </p></td> 
		            <td>  <textarea cols="30" rows="7" name="info"></textarea> </td>
		           </tr>                   
		         </table>
		         
				<input type="submit" value="Register" /> 
			</form>

</body>
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